The Bridge Project: Increasing Access to Care

1
The Bridge ProjectIncreasing Access to Care

• California Department of Public Health
• Office of AIDS
• Early Intervention Section
• Contact Carol.Crump_at_cdph.ca.gov

2
Bridge Project Origins and Purpose

• Funded by the state of California, CDC and HRSAs
  Minority AIDS Initiative in order to
• Assist in overcoming barriers to care
• Identify those who have tested HIV but never
  successfully accessed care
• Locate those who have dropped out of care and
  assist them as they re-engage in care

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Bridge was created because

• OA care and treatment sites reported that for
  persons of color and other vulnerable
  populations, too much time passed between HIV
  diagnosis and entry into care
• Too many clients were already very ill at the
  time of their initial enrollment in care
• For some, the enrollment process was complex,
  intimidating, or overwhelming

4
Bridge was created because

• Many clients from vulnerable populations failed
  to return after one or two appointments
• Even when enrolled, some were only marginally
  involved in their own care and/or were not
  adherent to care
• Others dropped out of care or become lost
  between the cracks of complex care and social
  service systems

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Bridge Goals

• To identify, reach, and engage in care HIV
  persons who have never received care or who have
  been lost to care
• To develop an alliance with those clients whose
  connection with care is fragile
• To strengthen client involvement in care
• To provide basic HIV treatment information and
  adherence support

6
Bridge Sites

• Bridge Workers are located in all of Californias
  36 Early Intervention Program sites. EIP
• is multidisciplinary and team-centered
• provides medical care, risk reduction counseling,
  health education and psychosocial support/case
  management for HIV persons
• Bridge Workers refer many-- but not all --
  clients to EIP. Their goal is to refer to the
  most appropriate care provider for each client

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Bridge Workers The Right People in the Right
Places

• Bridge Workers are peers with strong social and
  cultural ties to the community they serve
• Bridge Workers are certified HIV Treatment
  Educators who are also trained in outreach
• Bridge Workers are active members of the EIP care
  team, and are placed at the care site in order to
  build strong alliances with primary care providers

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Bridge Workers Connecting with Clients

• Hospitals and emergency rooms
• Street outreach conducted by the Bridge Workers
  themselves
• Referral by HIV test counselors who suspect a
  client may not connect with care
• Referral by EIP or other HIV care staff if a
  client has dropped out of care
• Other agencies Food bank, needle exchange

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What Weve Learned Reasons for Failure to Access
or Remain in HIV Care

• Mistrust of social service or care systems
• Cultural or language barriers
• Concerns for confidentiality
• Immigration status concerns
• Managing treatment regimens/side effects
• Mental health and/or substance abuse issues
• Low health literacy
• Negative experience with previous providers

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Bridge How the Intervention Works

• Reach out to clients, but reach out carefully
  --connect in their community and on their terms
• Focus on building a relationship first for
  out-of-care and lost-to-care clients, enrollment
  in care, partner disclosure, and other referrals
  should often wait until trust is established
• Stay connected and let the client set the pace!

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Bridge How It Works contd

• Assess systemic and psychosocial barriers to
  accessing or re-accessing care
• Assess available care and treatment resources for
  goodness of fit for each client
• Stay connected and let the client set the pace!

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Bridge How It Works contd

• Work with the care team to overcome any systemic
  barriers
• Work with the client to define incremental,
  achievable steps that can lead to enrollment in
  care
• Stay connected and let the client set the pace!

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Bridge How It Works contd

• Assist clients in understanding their treatment
  options
• Act as a client advocate with providers
• Act as a provider advocate with clients
• Assist the client in establishing a working
  alliance with care providers
• Stay connected and let the client set the pace!

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Bridge How It Works contd

• If providers identify a client whose engagement
  in care is slipping, they can connect that client
  with a Bridge Worker who will
• Assess barriers to engagement in care
• Team with the care site, providers, and client to
  overcome those barriers
• Strengthen client-provider alliances
• Stay connected and let the client set the pace!

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Bridge Clients HIV Exposure Reported by Gender

• Male Clients
• Sex with men 1702
• Sex with women 708
• IDU 439
• Transfusion/Surgery 7
• Birth 1
• Rape 1
• Other 43

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Bridge Clients HIV Exposure Reported by Gender

• Female Clients
• Sex with men 618
• Sex with women 47
• IDU 153
• Transfusion/Surgery 11
• Birth 2
• Rape 5
• Other 8

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Bridge Clients HIV Exposure Reported by Gender

• Transgender Clients
• Sex with men 41
• Sex with women 2
• IDU 8
• Other 1

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Bridge Clients 2004-2007

• EIP clients who were lost to care 1183
• Non-EIP clients who were lost to care 950
• Clients who had never received any previous HIV
  care 1054
• Non-EIP clients who have not disclosed whether
  theyve received care 112

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Bridge Clients by Ethnicity 2004 - 2007

• 
  Number Percent
• African American 695 23
• Asian/Pacific Islander 57 2
• Caucasian 824 28
• Latino 1293 44
• Native American 22 1
• Unspecified 69 2

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Bridge Barriers to Care for Latino/as

• Language It shouldnt be the burden of the
  Spanish speaker to cross that barrier
• More likely to self-treat or use community
  healers may avoid providers if given conflicting
  information or if provider seems judgmental
• Non-citizens are fearful of providers and often
  unaware of services they can safely receive

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Bridge Barriers to Care for Latinas

• Latinas report fear, shame and denial of illness
  as barriers to care
• Domestic violence is often a factor
• Personal health is a lower priority than the
  health of other family members
• Few providers offer genuinely family-centered
  service models

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Bridge Barriers to Care for African-Americans

• Stigma Can lead to denial of illness
• Mistrust of providers expecting to get lots of
  expensive pills that arent needed/will make me
  feel worse
• Historical distrust of health care systems
• Disproportionate rates of incarceration for both
  men and women

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Bridge Barriers to Care for Injection Drug Users

• Provider resistance to working with IDUs
• Provider tendency to push for substance abuse
  treatment
• HIV-infected IDUs have a greater burden of
  non-injection drug use and concurrent mental
  disorders than other populations
• Many have had negative experiences with providers